Tramadol denials in California external review

What the reviewers wrote

Where the denial was overturned

Findings: The physician reviewer found that Nature of Statutory Criteria/Case Summary: The patient requested authorization and coverage for the medication regimen of tramadol 50 mg tablets (90 tablets every 30 days).The Centers for Disease Control and Prevention (CDC) guidelines for opioid therapy state that, “For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy”.

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for oxycodone with acetaminophen tablets 5-325 mg and/or tramadol 50 mg. The Centers for Disease Control and Prevention (CDC) guidelines state that, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain.” Further, the CDC noted that, “If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” The Federation of State Medical Boards indicated that, “opioid therapy for chronic pain that is not cancer-related, or part of palliative care or end-of-life care, only when non-opioid and non-pharmacological options have not been effective and maintain opioid dosage as low as possible and continue only if clear and objective outcomes are being met.” The American Society of Interventional Pain Phys…

Where the denial was upheld

Nature of Statutory Criteria/Case Summary: The patient has requested authorization and coverage for tramadol. Findings: The physician reviewer found that On determining when to initiate or continue opioids for chronic pain, Dowell and colleagues report, “Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.” The authors further note, “Clinicians should evaluate benefits and harms with patients within one to four weeks of starting opioid therapy for chronic pain or of dose escalation.

Nature of Statutory Criteria/Case Summary: An enrollee has requested authorization and coverage for an increase in tramadol dose. The Health Plan has denied this request indicating that the requested medication regimen is not medically necessary for treatment of the enrollee’s medical condition. Nationally recognized evidence based medical guidelines recommend tramadol as an option for pain treatment. Tramadol is indicated for treatment of moderate to severe pain. There is limited information to recommend this drug for neuropathic pain. The immediate release formulation is recommended at a dose of 50 to 100 mg by mouth every four to six hours (not to exceed 400 mg per day). Opioids appear to be efficacious, but should be limited for short-term pain relief in patients with acute low back pain.

These outcomes describe eligible cases completed through California DMHC’s Independent Medical Review program. They do not estimate the chance that an internal appeal, an external review in another jurisdiction, or your individual case will succeed. Use the record to identify evidence patterns involving Tramadol, then check the rights and deadlines that apply to your plan.